Exercise-based cardiac rehabilitation in cardiac resynchronization therapy recipients: A primer for practicing clinicians

Abstract

Cardiac resynchronization therapy (CRT) is a therapeutic option of increasing importance for chronic heart failure (CHF) and criteria for implantation now concern a large amount of patient populations. As a consequence, subjects with ongoing CRT (or immediately after CRT implantation) are more often referred to Cardiac Rehabilitation (CR) programmes, and it has been recently estimated that about one third of CHF patients attending CR in Italy currently have this kind of device. The presence of CRT represents a modulating factor for exercise prescription and monitoring, since CRT patients may be considered per se as a target group for CR. Exercise therapy (ET) increases benefits from CRT on functional capacity, and recent evidence suggests an adjuvant role of ET in improving cardiovascular prognosis also. Both aerobic endurance and resistance training activities may involve CHF patients with CRT, while the potential role of aerobic interval training needs more studies and evidence. Prescription of an ET program should be associated with information regarding device programming and possible limiting factors associated with pacing therapy, tailoring of the basic principles of ET (in terms of type of exercise, intensity and program duration) in this patient group is mandatory. Cardiac resynchronization therapy in heart failureHeart failure (HF) is a clinical syndrome characterized by typical symptoms (e.g., breathlessness, ankle swelling and fatigue) leading to marked disability and impaired life expectancy. The prevalence of HF is approximately 1-2% of the adult population in developed countries, rising to ≥10% among people >70 years of age [1][2][3]. Cardiac resynchronization therapy (CRT) represents an important advancement in HF treatment by targeting ventricular dyssynchrony, a condition occurring in up to a third of patients with severe systolic HF [4]. CRT is based on the addiction of a third left ventricular pacing lead to a standard pacemaker (CRT-P) or defibrillator system (CRT-D) that generally includes only two right side leads (Figure 1) The left side lead is generally placed into the lateral or posterolateral wall of the left ventricle, and when the two leads are activated, a coordinated pacing of the left ventricle and right ventricle is obtained [5]. Several randomized, controlled clinical studies have demonstrated that CRT has several positive clinical effects, including: improvement in cardiac function and structure, quality of life and exercise capacity, as well as reduction in heart failure hospitalization and mortality from progressive heart failure (Table 1). Moreover, by improving cardiac performance and efficiency, CRT favorably impacts cardiac autonomic control, potentially contributing to reverse remodeling of the left ventricle [6]. As in the case of implantable cardioverter defibrillator (ICD) devices [7], implantation policies may have significant impact on public health expenditure and appropriate patient selection for CRT is needed in order to maximize its benefits and cost-eff...

Efficacy and Safety of Exercise Rehabilitation for Heart Failure Patients With Cardiac Resynchronization Therapy: A Systematic Review and Meta-Analysis

“…The possible explanation for these results is that the significant favorable effect of exercise training on events in those without a device was abrogated by the presence of BiV pacing (Zeitler et al, 2015). The most appropriate time window is not clear; it has also been recommended that exercise training begins at least 1 week after CRT implantation (Ambrosetti et al, 2017). The interval time between CRT implantation and exercise training in the included studies reported was at least 2 weeks.…”

Aerobic exercise prescription in heart failure patients with cardiac resynchronization therapy

“…This includes skin healing, which then should be responded by restriction of upper extremity motions. 22 However, after 24 hours of device implantation, light upper extremity motion will be required to obtain a positive effect on joint immobilization. 24 It was shown through a meta-analysis of exercises in patients with CRT and CRT-D that there is a 5% chance of device malfunction during the first 12 months after implantation, and 1.8% chance of infection at the implantation site, which then highlights the need of wound monitoring.…”

“…[18][19][20][21] In the context of exercise in CRT-D recipients, it is essential to determine shock threshold as it was mentioned that ICD shocks are associated with reduced quality of life, hence, would affect exercise compliance and physical activity. 10,22,23 Recent Cochrane meta-analysis had shown that studies on exercise in ICD recipients have better effects toward receiving appropriate shocks, however, this result was still inconclusive because of low level of available evidence. 10,11 Studies had mentioned that resting parasympathetic tone was found to raise along with exercise, and this would further protect against ventricular arrhythmias.…”

“…8,10 It could then be drawn out that exercise in implantable cardiac device recipients would provide its beneficial effects through amelioration of autonomic tone. 8,22 With all these facts unfolded, it could be seen that exercise is safe and beneficial for CRT patients, and what lies beyond is how to effectively prescribe these exercise training. Being the core of physical medicine and rehabilitation field, in order to achieve targeted goals with tailor-made exercise regimen, a detailed exercise prescription should comprise of exercise frequency, intensity, type, and time.…”

A szívbetegek rehabilitációjának sportos arca

“…A reszinkronizációs kezelésben részesültek többsége részesül a rehabilitációs edzésprogramokban, Olaszországban a résztvevők mintegy harmadát ők teszik ki [29].…”